The Improvement Focused Governance Cycle

The following cycle can be followed to support dialogue,
planning and actions that promote the reliable implementation of
improvement focused governance across NHSScotland.

Each of these phases within the cycle support an improvement
focused governance approach. Tips on how to retain an improvement
focus throughout this cycle are outlined in the remaining sections
of this booklet.

Considering the right information

Improvement focused governance activity is only possible if the
right information is being presented for review. Papers that
progress through a series of stages before being considered by a
Board or Board level committee should become progressively shorter
in length as they make progress through and the information 'flows'
through the system.

Non-Executive Directors should not be considering documents
developed for other purposes/groups. Generally speaking a paper
being considered by a Board level committee should be shorter and
more condensed than a paper previously considered by a contributing
Committee or an individual Directorate. The challenge often for an
effective improvement focused governance system is to address the
tensions between 'work and re-work' of papers and the need for
non-duplicative reports to be submitted for a range of meetings; to
provide appropriate checks and balances while minimising costs of
producing papers and ensuring testing and improvements.

Too much information presented too close to the date of a
meeting does not allow for assimilation of the details, preparation
and identification of issues for reflection and dialogue.

"Recycled" reports (which may not contain the most up to date
information or which haven't been revised to consider the purpose
of presenting the report to more than one committee) are generally
unhelpful. Improvement focused governance is better served by
ensuring all reports clearly describe the specific aim in
presenting the report content across different groups.

Improvement focused governance is best served when there is a
balance of information presented in relation to the past and to the
future.

If the right information is presented it needs to be the right
amount of information to support interpretation of the issue being
considered. Important detail on context should also be provided to
support discussion, decision-making and any actions to be
agreed.

Information presented should focus whenever possible on both
process and outcome data - covering what is known about the
contributors to variation and the implications of this for
improvement focused action.

Information reports should be brief and present information
using a combination of text as well as graphically/diagrammatically
when possible.

While it is important to ensure that there is an appropriate
balance of information on services and processes that are
working/performing well, Non-Executive Directors should ensure that
appropriate focus is given to understanding powerful and important
opportunities for improvement that can be identified from system
defects/failures.
[3]

Data for dialogue

The guide "Quality Improvement and Measurement: What
Non-Executive Directors need to know" highlights issues to be
considered when reviewing data. As more NHSScotland staff becomes
aware of quality improvement approaches to support change and
improvement, questions may arise in relation to when information is
to be considered for 'judgment' or 'improvement'.

It is important to understand the purpose that informed the
collection of the data (
i.e. data collected for improvement
will have different characteristics to that collected for
submission to inform national statistics).

All data and information should support an improvement focused
dialogue: assurance that there is good staff engagement in
collecting data over time and across processes to support
improvement can be as important as receiving assurance that data
are showing a significant trend or shift in one outcome
measure.

What Non-Executive Directors can do to ensure that the
right information is collected and presented

Support and encourage the presentation of timely information.
This should also clearly outline why this is being presented and
what decisions are required.

Consider processes, outcomes and experiences when reviewing
information - and if these are not presented then ask for this
information.

Communicate expectations that information is presented
succinctly, with background information and in a way that
reflects priorities for services and continuous improvement.

Discourage the use of 'The Board noted the paper' or 'For
information' items and encourage more detail on what it is that
is to be noted and how the information being tabled relates to
the requirement for any actions to support or enhance
services.

Actions identified should be learning and 'celebration' focused
as well as those focusing remediation and the need for
improvement.

What 'lens' is needed to consider information?

NHSScotland places quality of care at the centre of everything
we do. Improvement focused governance is best facilitated by
considering all information that is presented to Boards through
this 'lens'.

Appendix 2 of the booklet in this series "Quality Improvement
and Measurement. What Non Executive Directors Need to Know" covers
key issues in measurement, understanding variation and data
presentation that should be considered when reviewing information
at this part in an improvement focused governance cycle.

The processes and reporting cycles for review of information
being considered should be scheduled in advance and for any issues
arising outside of this cycle, clearly agreed in advance.

Information should be considered from the perspectives of
patients, service users and/or staff members. This can then support
a conversation more focused on what matters to the people directly
affected by the issues being considered. Actions can then be more
effectively focused on what will be required to support improvement
in the areas identified.

The booklet as part of this series on "Person-Centred Care"
describes the way in which a person-centred 'lens' also be used to
consider the ways in which services and thinking about service
delivery are enhanced by focusing more on 'What matters to...' than
'What's the matter with...?' For example, a Board paper that
collates information on future plans for people living with
neurological conditions that makes no reference to considering what
matters most to people may require an action to collect this
information and identify changes and improvements needed.

Linking Governance Discussions

Information from other related governance
conversations/processes may need to be considered when identifying
what action to take - for example, a discussion in a Clinical
Governance meeting might identify the need to support more doctors
to develop skills in improvement science. This would raise the need
to have a link with Staff Governance or Educational Governance
process where additional work demands and training arising from the
agreed action could be considered. Integrated governance meetings,
frameworks and discussions can also help.

When interpreting information it can be important to focus on
the process factors at play - as opposed to focusing solely on
single examples, events or descriptions of a process at a single
point in time).

Concentration on the 'whole' picture as opposed to selective
parts often identifies areas where action will be required to
support continuous improvement in quality or efficiency of
services. This can be forgotten or overlooked when there is
pressure to change or initial distress about the information and
change processes.

It is important to remember that 'big' changes do not
necessarily require 'big' action.

What Non-Executive Directors can do to ensure that
information is interpreted to support the identification of
actions

Consider what will be required in terms of staff involvement,
engagement and the related requirements to implement the
action.

Consider whether the voices and experiences of people who
have direct experience of the services being considered (patients
and staff) influence the discussion on actions required.

Ensure that the actions that have been identified as
necessary address the need to take actions that will change
processes most likely to impact on outcomes and experience.

Remember to consider the risk that actions are being
formulated on the basis of 'noise' in the information being
presented - if this is not clear, ask for the 'signal' and
'noise' issue to be explained.

Improving the Quality of Action Plans

Governance processes and meetings often result in agreement of
actions that need to be implemented to sustain, spread or implement
continuous improvement. Actions must take account of the need to
consider the impact on people, processes, outcomes and
finances.

The development of an 'action plan' is often the response when a
need for change, improvement or assurance has been identified.
Governance and improvement meetings also often summarise the
actions to be taken following consideration of the issue.

Improvement focused governance needs to make sure that the
'right' actions are identified, that these are described clearly
and that links are made with measures that are sensitive to the
changes that will be needed to monitor impact and outcomes.

Getting the right measure of progress is one of the most
important actions that can arise from consideration of information
presented.

Measures of Implementation AND Measures of
Effectiveness

Clearly described actions need to be linked with measures of
implementation and with measurement of effectiveness (Kaiser
Permanente, 2016). Too much emphasis is often placed on measures of
implementation - committee minutes or other documents being
circulated.

A Measure of Implementation (MoI) is evidence that the action
was implemented. It describes what was done to verify the action
was instituted. However, it does not address the effectiveness of
the measure.

A Measure of Effectiveness (MoE) provides evidence that the
action was effective and has the desired impact. This can include
monitoring of processes for an agreed period (possibly as part of
an improvement programme) and reporting outcomes thereafter to the
Board.

The following table outlines examples of Measures of
Implementation and Measures of Effectiveness:

Action

Measure of Implementation

Measure of Effectiveness

Increase staff numbers on evening shift

Staff increased by one nurse on evenings is demonstrated
on staffing sheet

Improved transfer times due to additional staff member
in evenings

One Action, One Person

There needs to be clarity of responsibility for any actions
arising from consideration of information presented through a
governance process. Ideally there should be one owner responsible
for implementation of the action outlined, ensuring that the
efforts of the range of people involved with the action are
coordinated and described succinctly for committee or Group
members. This avoids diffusion of responsibility and related
psychological factors that can blur lines of accountability.

Putting it all together…

Would you be able to summarise how the decisions made in a
governance process support staff to deliver high quality outcomes,
positive experiences or learning how to make things better? If not,
how could this happen?

It can be useful to think about how decisions and actions
reached collectively deliver strategic aims. This is sometimes
referred to as a strategic narrative covering the range of work
being undertaken in respect of quality, safe, effective,
person-centred care, supporting the improvement of outcomes for the
population served.

Being able to articulate a narrative that engages hearts and
minds of staff and those receiving services will support an
improvement focus to the actions agreed in support of improvement
focused governance.

What Non-Executive Directors can do to ensure that the
right actions are taken following consideration of
information?

Make sure that it is clear what action(s) have been agreed to
determine what needs to be done, by whom and when? There should
be one person responsible for leading and coordinating the work
on the action.

For all actions identified ensure that you have answers to
the following questions:

How will you know that the action agreed has been
implemented?

How will you know if the action has had any impact when it
is implemented?

Is the action strong enough to lead to change?

Who is accountable for the delivery, monitoring and
reporting of the progress and improvement against the actions
agreed?

Is it clear how actions will support the main strategic
priorities of the Board?

Governance committees should have clearly described plans that
consider how the operating effectiveness of a committee or
governance process will be reviewed. This can be done by asking for
feedback at the end of meetings or by the collection of responses
to some key questions on the process of participating in the
meeting.

Measures of effectiveness from previously agreed actions should
be considered when determining the impact. This ensures that
progress is noted, learning from the work
is identified and that the links to other important
strategic priorities can be emphasised.

The possible impact of actions on other parts of a system or
process needs to be considered and, if necessary, actions agreed to
monitor this and review as required.

What Non-Executive Directors can do to ensure that the
right actions are taken following consideration of
information?

Make sure that you are presented with information that allows
you to assess whether actions that have been identified
previously have been effectively implemented. This will depend on
there being an effective way of tracking the actions (including
linked actions) that are identified.

Monitoring engagement with stakeholders and how this has
influenced actions and evaluation of the impact of actions on
priority outcomes.

Consider whether the actions taken have addressed the need to
have a 'whole-system' focus.

The Board should consider the benefits of an integrated overview
within and between Governance processes/committees. Non Executive
Directors have a central role in identifying interdependencies
across actions or any themes in respect of approach to change,
culture, values, leadership or factors.

This could involve a review of themes in information being
presented, actions being identified and processes that are being
monitored. This could involve the monitoring of themes within the
work of a committee.

For example, a Clinical Governance Committee (or equivalent) may
consider a range of approaches being taken to improve patient
safety and want to comment on the successes in staff engagement or
leadership that they would like to encourage and support within
another area.

An Information Governance Committee might have identified that
resources are being mentioned as contributory to meeting statutory
deadlines in both Health Records and Freedom of Information support
services and ask for actions to be considered to develop and test a
more efficient streamlined support process.

Information on impact will often be reported in dashboards.
These need to reflect the priority areas of focus. If actions that
have been identified to support improvement are aligned with
outcome and experience data then these will rightly feature in the
dashboards being presented, supporting dialogue about the impact of
the actions that have previously been agreed.

The following dashboards illustrate the importance of
considering whether the right measures, measured right, are being
presented. In the first example (Figure 1) the right measures are
available for the purpose involved (safely flying a plane):

Are the measures presented appropriately for
purpose?

Figure 1 - Right Measures for Purpose

Figure 2 - Wrong Measures for Purpose

If the measures chosen are not relevant to the agreed purpose
then problems will arise in being able to evaluate whether aims are
being achieved and, in the worst case, can actually lead to poor
decisions and increased risk. By illustration of this point, figure
2 shows a plane dashboard populated by the wrong measures.

It is also possible to measure the right things but in ways that
are less useful (see Figure 3).

Consider the dials in the pictures above but presented in a
manner that is less than helpful for the purpose: